Nursing Reports 2014; volume 4:3225

Pain management after their management. As part of quality care assurance, the overall purpose of this study Correspondence: Margareta Warrén Stomberg, lung surgery was to explore patients’ experience of pain University of Gothenburg/The Sahlgrenska after lung surgery and, from their perspective, Academy, Institute of Health and Care Sciences, Maria Frödin,1 evaluate the quality as well as satisfaction PO Box 457, SE 405 30 Gothenburg, Sweden. Margareta Warrén Stomberg2 regarding the postoperative . Tel.: +46.31.7866026 - Fax: +46.31.7866050. E-mail: [email protected] 1Sahlgrenska University Hospital/Mölndal, Mölndal; 2University of Surgical procedure and Key words: postoperative pain management, lung Gothenburg/The Sahlgrenska Academy, pain managements surgery, satisfaction, expectation. Institute of Health and Care Sciences, In lung surgery, the surgical technique is either Contributions: MWS, study design, manuscript Gothenburg, Sweden an open one via thoracotomy or video-assisted analysis, preparation and final editing; MF, design, thoracic surgery (VATS) using a minimally data collection, data analysis and manuscript invasive endoscopic procedure. Thoracic preparation. Both authors read and approved the epidural analgesia (TEA), has been the golden final manuscript, as well as the revision. Abstract standard of pain management after lung sur- gery via thoracotomy.6,7 However, paravertebral Conflict of interests: the authors declare no block, (PVB), has been shown to provide compa- potential conflict of interests. Pain management is an integral challenge in rable pain relief to TEA, but with fewer side nursing and includes the responsibility of Received for publication: 11 March 2014. effects.7,8 If TEA or PVB are not suitable, inter- managing patients’ pain, evaluating pain Revision received: 29 May 2014. costal nerve blocks, bolus and continuous infu- therapy and ensuring the quality of care. The Accepted for publication: 30 May 2014. sion, combined with IV , are recom- aims of this study were to explore patients’ mended. Complementary medications as part of This work is licensed under a Creative Commons experiences of pain after lung surgery and multimodal analgesia, such as paracetamol, Attribution NonCommercial 3.0 License (CC BY- evaluate their satisfaction with the postoper- weak opioids and non-steroidal anti-inflamma- NC 3.0). ative pain management. A descriptive design tory drugs, are also recommended.9,7 was used which studied 51 participants only©Copyright M. Frödin and M. Warrén Stomberg, undergoing lung surgery. The incidence of 2014 moderate postoperative pain varied from 36- Acute and prolonged Licensee PAGEPress, Italy 58% among the participants and severe pain post-surgical pain Nursing Reports 2014; 4:3225 doi:10.4081/nursrep.2014.3225 from 11-26%, during their hospital stay. A prolonged and high impulse flow inuse a nerve Thirty-nine percent had more pain than can lead to a persistent up-regulation of activ- expected. After three months, 20% experi- ity, from the spine and inwardly. This refers to enced moderate pain and 4% experienced be wind-up, indicating the pain has been sus- lems arising from POPM,13 which also affect severe pain, while after six months, 16% taining and strengthened as well. A central patients’ experiences of and satisfaction with experienced moderate pain. The desired sensitization may also appear with increased the nursing care provided. quality of care goal was not fully achieved. sensitivity in the receptors around the injured Wilson14 showed that specialist nurses have a We conclude that a large number of patients area, which leads to a conversion of pressure more comprehensive knowledge base in gen- experienced moderate and severe postopera- and touch signals to nociceptive signals, which eral pain management, compared to general tive pain and more than one third had more in turn indicate pain. Offensive and multi- nurses. It seems this knowledge base was pain than expected. However, 88% were satis- modal pain management minimizes the risk of fied with the pain management. The findings secondary and the wind-up phe- influenced by the specialist nurses’ education confirm the severity of pain experienced nomena and therefore the development of rather than their experience of years working 11,15 after lung surgery and facilitate the apparent .6 Steegers et al.10 found that up to in the nursing profession. Other studies need for the continued improvement of post- half of the patients with chronic pain did not have found a discrepancy between patients’ operative pain management following this have a neuropathic pain component, which and nurses’ pain reports. The result indicated procedure. suggests other causes for the chronic pain, that nurses overestimated mild pain and Non-commercialsuch as a visceral pain component. underestimated severe pain.11 Dihle et al.15 Furthermore, a number of predisposing factors observed nurses’ actions and after interview- for the development of chronic pain and disor- ing them found a discrepancy between their Introduction der after surgery have been identified: preop- words and actions in the postoperative pain erative pain and anxiety, female sex, type of management, which demonstrated that the 1,3 Patients undergoing lung surgery run a risk of surgery, severe pain during the first few post- nurses had theoretical knowledge about from postoperative pain and some operative days, depression and anxiety, young POPM, but did not always use it in the clinical 3,11 1,10,12 may develop chronic pain.1,2 Chronic pain has age, and the length of surgery. setting. Nurses with specialist training are been found in 21-61% of patients after lung closely involved in the peri-operative pain surgery.3 Furthermore, studies have found that Nursing perspective management. They have a responsibility to lung surgery may cause long-term negative in postoperative pain management effectively manage patients’ pain, offer infor- effects for the patients, in terms of suffering, Pain management for surgical patients is inte- mation and education to patients about differ- reduced quality of life and an ultimately gral to nursing. The knowledge and attitude of ent options regarding pain management, as increased cost to society.4,5 According to the nurses towards pain management will affect well as ensure that patients’ pain problems are national guidelines developed by the Swedish patients’ postoperative pain management recorded and evaluated.16 Society of Anaesthesia and Intensive Care, (POPM). Educational programs have proven to The aims of this study were to explore pain should be treated preventively, using an increase nurses’ knowledge about POPM and patients’ experience of pain after lung surgery individual approach that involves patients in their competence of managing patient prob- and from the patients’ perspective, evaluate

[Nursing Reports 2014; 4:3225] [page 1] Article the quality of and satisfaction with the postop- naire, where higher values indicated higher pleted the Swedish version of the HAD scale erative pain management. quality of pain management, scored on a 5- during their preoperative ward visit. They point scale from 1=strongly disagree to also completed the HAD scale on the day of 5=strongly agree. It was suggested that a mean discharge or latest on POD 5. In order to score of >4. 5 indicated a high quality of care;17 assess the quality of postoperative pain man- Materials and Methods and <4 a low quality of care.18,19 To achieve a agement, the patients completed the Swedish high quality of care in the postoperative pain version of the SCQIPP questionnaire on the This was a descriptive study which consecu- management, the desired total mean score day of discharge or POD 5. Fifteen patients tively included participants from the waiting must be ≥63/70 (14 items ¥ 4.5). The comple- (29%) asked the data collector to read the list for lung surgery, from May to December mentary questions in the instrument were: questions and complete the answers in the 2011, at a department of vascular and cardio- Has the patient had more pain than expected? HAD scale preoperatively and five (10%) thoracic surgery, at a university hospital in rated with Yes/No. How satisfied/dissatisfied received help to complete the questionnaires southwest Sweden. was the patient with the overall pain manage- on discharge day or POD 5. ment? scored on a 5-point Likert scale ranging All the patients received the same preoperative Sample from 1=very dissatisfied to 5=very satisfied.17 information. What distinguishes the study In this study 52 patients were consecutively from the general ward routine was the regular invited to participate. Inclusion criteria were Hospital anxiety and depression measuring of the VAS score, at rest and when adult patients (aged 18 or above) undergoing scale coughing, during the hospital stay until dis- charge or POD 5. Prior to the study, the gener- elective lung surgery and able to read and The hospital anxiety and depression (HAD) al ward routine was to discontinue document- understand the questions in Swedish. Patients scale measured anxiety and depression and ing the VAS score after the chest tube had been were excluded if they were diagnosed with each item was rated between 0-3. The total mental disorders, experienced pain for more removed. score ranged from 0-21 in the each of the two On the day of the surgery, POD 0, the VAS than three months before surgery and/or had a subscales (HAD-A and HAD-D). HAD-A and/or regular intake of analgesic(s) at least three scores were measured directly at the post- HAD-D ≤7 would indicate no or very mild anx- days/week, required emergency care, and/or care unit (PACU), at rest and when iety or depression, whereas their scores ≥8-10 coughing,only by the ICU duty nurse, and on the had lung surgery previously. Ten patients from could indicate a possible anxiety or depression the list of scheduled surgery were not invited general surgical ward by the registered nurse and scores ≥11 could indicate a probable anxi- responsible for the patients. The duty nurse to participate due to one of the above exclusion ety or depression.20 criteria. According to current routine practice repeated the same procedure on the ward at 12 useam and 6 pm. The VAS scores, patients’ charac- of the surgical unit for lung surgery, the Pain management routines patients were supposed to have about five days teristics and pain treatment were documented of hospital stay. On the postoperative day According to the local guidelines in Sweden, in a specific study protocol. All members of the (POD) 3, 4 and 5, four, 11 and 11 patients were TEA is the first choice of postoperative pain staff were informed about the study. The data discharged respectively. At the third and sixth management. A TEA catheter is inserted and collector conducted a pain assessment inter- month of data collection, a total of two patients tested either the day prior to surgery or on the view three respectively six months after the were withdrawn due to critical illness (i.e., the same day and activated at anesthesia induc- surgery via a telephone call. The questions remaining n=49). tion. A bolus dose of sufentanil and bupivacain were: Do you have any pain related to the lung is administered before it is activated. TEA con- surgery?. If yes: VAS score at rest and at Instruments used to measure pain tinues until the chest tube is removed. The worst/coughing. epidural infusion is a combination of bupiva- and quality of pain management cain 1 mg/mL, fentanyl 2 mg/mL and adrenalin Data analysis The visual analogue scale (VAS) was used to 2 mg/mL. VAS <40 mm has to be achieved assess patients’ experience of pain after the The data was coded and analyzed using the before the patient returns to the general ward. SPSS version 20.0 (IBM Corp., Armonk, NY, surgical procedure. The VAS score was Each patient has a protocol for the prescribed assessed by the patients themselves and, in USA). For descriptive purposes, continuous analgesic drugs, rates, as well as a checklist for variables are presented as mean and standard the study, the recommended VAS score target basic and specific controls. This is document- was VAS <40 mm. deviation or median and min/max where appro- Non-commercialed on at least every nursing shift, i.e., three priate. Categorical data are presented as num- times per day. Strategic and clinical quality bers and percentages. VAS and HAD are consid- IV analgesic is given to those patients for ered qualitative variables. The variables were indicators in postoperative pain whom TEA is unsuitable. The drug used is examined using descriptive statistics and plots management morphine 1 mg/mL as infusion and bolus, pro to assess normality, distribution and checking The validated Swedish version of the strategic re nata. The patients with IV analgesic also for outliners. For the analysis of the difference and clinical quality indicators in postoperative received intercostal nerve block, as a single between groups, non-parametric tests were pain management (SCQIPP) questionnaire injection at the end of surgery. As additional used, due to the small sample sizes and the not with 14 items was adopted to assess the quali- oral analgesic, oxycodone was given twice a normally distributed groups. Mann-Whitney U- ty of postoperative pain management. The day and as rescue analgesic. test (M-W) was used to test differences between items mainly covered a few important aspects, two independent variables. Pearsons’ Chi- including preoperative education about pain Procedure square test was used to explore the relation- management and treatment offered after sur- After informed consent the participants were ships between every two independent categori- gery, when the patient should be asked about asked about preoperative pain and regular cal variables in this study. Wilcoxon signed-rank his/her pain at movement, trusting the patient intake of analgesia, as well as other patient test was used to test the differences of paired about his/her pain perception, treating the characteristics. A regular intake of analgesia values or percentages between two repeated pain adequately, and cooperative approach to was defined as more than three times per measurements. The level of statistical signifi- pain treatment. The items in the question- week. The patients included in the study com- cance was set at 0.05.

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Ethical considerations experience of pain varied widely between par- and severe pain with a variation between 11- Ethical approval was obtained from The Ethics ticipants. 26% during POD 0-5, when coughing, in the Committee of the University of Gothenburg, Patients receiving IV analgesic recorded a sig- entire study group, as illustrated in Figure 2. Sweden (code 245-11), following the Helsinki nificantly higher VAS score at rest, in PACU, Declaration21 regulations regarding human (P=0.049 M-W), and during POD 1, at rest Quality of pain management subjects research. (P=0.004 M-W), compared to the TEA group. measured by the strategic and No significant differences were found in the clinical quality indicators in measured pain scores between women and men who received TEA. Younger patients, <65 postoperative pain management Results years (median 65), experienced higher pain questionnaire assessment levels compared to the elderly patients, ≥65 The quality of pain management assessment Of the 52 patients invited, 51 had given years, in the entire study group, and when shows that the achieved total mean score in informed consent to participate in this study. coughing. the SCQIPP questionnaire was a total of 61 The main reasons for refusal of participation A comparison of pain scores and discharge day, out of 70, a result that was not high enough to were fatigue and poor health. Characteristics <5 and ≥5, (median 5), in the entire study indicate an overall high quality of care, which of the participants are summarized in Table 1. group, revealed no significant differences. A required >63. However, high quality of care comparison of LoS revealed a significantly was found in individual questions concern- Pain management and surgical higher pain score during POD 1-2, when LoS ing; the staff believed them when they told procedure was ≥91 min (median=91). This applied to the them about the pain, the staff cooperated well entire study group and the TEA group, reveal- in treating their pain, they asked them every TEA was given to 44/51 patients, 28/44 were ing the pain score was significantly higher day to measure pain. Areas for improvement female. In 34/44, no TEA problems were found. both at rest (P=0.018 M-W) and when cough- were found in subscale communication; the Of identified TEA problems; dislocation was ing (P=0.030 M-W). staffs’ knowledge about the pain treatment found in 6/10, problem with the patient-con- they had received, action subscale; receiving trolled analgesia (PCA) pumps in 3/10, and side help in finding a comfortable position in bed, effects in 1/10. Those with dislocation problems Mild (visual analogue scale: 0-30 andonly environment; there was no peace and received a new epidural catheter, those with mm), moderate (visual analogue quiet in the room at night. Measuring pump problems received a new PCA pump, and scale: 31-70 mm) or severe pain patients’ satisfaction revealed that 88% of the a lower epidural infusion rate was prescribed (visual analogue scale: 71-100 mm) patients were satisfied or very satisfied with where low blood pressure was reported. None of A division of VAS into three categoriesuse shows the pain management. Those patients report- them were converted to IV analgesic. The rea- that moderate pain was found with quite a lin- ing more pain than expected were less satis- sons for not receiving TEA were: failure to ear distribution in a variation between 22-58% fied with the quality of pain management. insert the epidural catheter 4/7, the catheter was inserted but did not function 1/7, the patient had a medical condition which was con- traindication for epidural catheter 1/7, and the patient declined the treatment 1/7. All the Table 1. Patient characteristics. patients in the IV analgesic group were male No. (%) Mean, SD Median Min/Max and the surgical procedures were thoracotomy 6/7 and VATS 1/7. Length of surgery (LoS) and Age 51 61.1, 14.5 65.0 18-82 discharge day are found in Table 2. Female 28 (54.9) 62.0, 10.5 64.5 39-79 Male 23 (45.1) 60.1, 18.3 65.0 18-82 Pain intensity during hospital stay, ASA* mean and standard deviation Class I-II 30 (58.8) --- (visual analogue scale: 0-100 mm) Class III 21 (41.2) --- In the TEA group, the mean pain score at rest Non-commercialSD, standard deviation.*ASA (I-V) is a classification of anesthesia risk factors according to the American Society of Anesthesiology. varied slightly. On POD 0-5, the mean pain score was <22 mm, at each subsequent time. When coughing, the mean pain score at PACU was 24 mm, subsequently increasing with a peak on POD 2 of 52 mm, and there- Table 2. Length of surgery and discharge day. after ending on POD 5 with a mean pain No. LoS (min) Min/Max Discharge day Min/Max score of 48 mm. Median Median In the IV analgesic group, the mean pain score at rest was 49 mm in PACU. On the general All surgery procedures 51 91 16/271 5 3/21 surgical ward during POD 0, the mean pain Thoracotomy 44 91 16/271 6 3/21 score was 48 mm, thereafter subsequently VATS 7 99 33/206 4 3/6 decreasing until POD 4 to <15 mm. The mean Wedge resection 20 57 16/155 5 3/10 score when coughing, at PACU, was 49 mm, Lobectomy 27 120 40/271 6 3/21 subsequently increasing with a peak of 67 mm on POD 1, thereafter decreasing to 48 mm on Pulmectomy 4 80 41/95 6 5/8 POD 4. The mean pain score POD 0-4, in the TEA 44 89 16/271 6 3/17 two different pain treatment groups, is shown IV analgesic 7 93 25/206 5 3/21 in Figure 1. The standard deviation of the LoS, length of surgery; VATS, video-assisted thoracic surgery; TEA, thoracic epidural analgesia.

[Nursing Reports 2014; 4:3225] [page 3] Article

More pain than expected was found in 39% of the patients.

Hospital anxiety and depression scale analysis No significant difference in anxiety or depres- sion was found by comparing the HAD score pre- and postoperatively and also no signifi- cant correlation between the preoperative anx- iety and the postoperative pain. A separate comparison of gender revealed that women had a significant reduction of anxiety postop- eratively (P=0.007 Wilcoxon signed-rank test).

Pain three and six months, mild (0-30 mm), moderate (31-70 mm), Figure 1. Mean visual analogue scale (VAS) score (0-100); thoracic epidural analgesia (TEA) severe (71-100 mm) pain and IV analgesic group, at rest and coughing, during post-operative day (POD) 0-4. At the three month follow up, 76% experienced mild pain, 20% experienced moderate pain and 4% experienced severe pain, related to surgery. At the sixth month, 84% experienced mild pain, 16% experienced moderate pain and no one experienced severe pain, in the entire study group. A significant reduction of pain from the third to the sixth month, (P=0.007, only using Wilcoxon signed-rank test), was found within the entire group (Figure 3). At the three month follow up, 36% required anal- gesic for the pain and, at the six month follow use up, 14% required analgesic for the pain. One of the patients required the opioid analgesic oxy- codone after both three and six months.

Discussion

The clinical pain guideline with the gold stan- dard VAS score of <40 mm as the best practice, Figure 2. Percent of patients, in the total group, with moderate and severe pain, when coughing, during their hospital stay. Post-operative day (POD) 0-2, n=51; POD 3, n=47; during the hospital stay, was achieved in this POD 4, n=36; POD 5, n=25. VAS, visual analogue scale. study when the pain score was measured at rest, but not when coughing. During POD 1-5, the mean pain score increased to VAS 40-50 mm, when coughing, regardless of pain treat- ment. Comparing the two different types of pain treatment, IV analgesic had significantlyNon-commercial higher pain scores compared to the TEA group, during the first two postoperative days. This result is not unexpected from a clinical point of view within the hospital. However, due to the small sample size, this finding cannot be gen- eralized to a larger population. The high pain score in the TEA group POD 0-2, when cough- ing, was not expected, as TEA is a well-docu- mented superior treatment compared to other methods of pain management after lung sur- gery.9,7 There were no differences between the two groups on PODs 2-4, similar to a previous study performed in the same department, which compared TEA and IV analgesic after cardiac surgery.22 In that study, preoperative anxiety among the surgical patients was found Figure 3. Percentages of patients with, mild, moderate or severe pain at three and six to be associated with their levels of postopera- months, n=49. VAS, visual analogue scale.

[page 4] [Nursing Reports 2014; 4:3225] Article tive pain;12 however, this close relationship more pain than expected and 15% reported was not found in this study. more pain than expected at a department of References The findings that younger patients, aged <65 general surgery. Idvall et al.17 found that 24% years, had more pain than older patients dur- of the patients reported more pain than 1. Kehlet H, Jensen TS, Woolf CJ. Persistent ing the hospital stay and those with a longer expected. The patients in both studies postsurgical pain: risk factors and preven- surgery time, more than 90 min, also experi- assessed the quality of care lower, which is tion. Lancet 2006;367:1618-25. enced more pain than patients with a shorter similar to this study. 2. Macrae WA. Chronic post-surgical pain: 10 surgery time (e.g., on the first postoperative Stomberg and Öman28 discuss the importance years on. Br J Anaesth 2008;101:77-86. day only), were consistent with our previous of having a realistic expectation of postopera- 3. Ochroch EA, Gottschalk A, Augostides J, et understanding about the predictive factors of tive pain, maintaining that nurses play a vital al. Long-term pain and activity during postoperative pain.1 role in informing the patients before surgery, recovery from major thoracotomy using tho- The results in this study are consistent with to promote a realistic expectation of postoper- racic epidural analgesia. Anesthesiology others that report moderate and severe pain ative pain. The discrepancy between expecta- 2002;97:1234-44. after surgery and insufficient pain manage- tion and satisfaction is an interesting issue 4. Breivik H, Collett B, Ventafridda V, et al. ment, despite available multimodal analge- and quite complex. It demonstrates the com- Survey of chronic pain in Europe: preva- sia.23,24 Tocher et al.24 found that almost 70% of plexity of evaluating postoperative pain man- lence, impact on daily life, and treatment. the patients experienced pain during their agement and measuring satisfaction with pain Eur J Pain 2006;10:287-333. hospital stay, 26% of the patients had pain all management alone is not recommended.25 5. Wildgaard K, Ravn J, Nikolajsen L, et al. or most of the time and 12% had severe pain. The experienced pain after three and six Consequences of persistent pain after Lorentzen et al.23 reported an incidence of months in this study is difficult to compare lung cancer surgery: a nationwide ques- moderate pain in 51% of the patients and 36% with other studies, due to the lack of a unani- tionnaire study. Acta Anaesthesiol Scand experienced severe pain postoperatively. mous definition of persistent/chronic post-sur- 2011;55:60-8. 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Postoperative pain man- study from Germany shows that 55% of the A large number of patients experienced moder- agement: predictors, barriers and out- patients who had undergone surgery were dis- ate and severe pain postoperatively and more come. Göteborg: Institute of Health and satisfied with their pain management.Non-commercial26 than one-third had more severe pain than Care Sciences, The Sahlgrenska Academy Svensson et al.25 found that most of the expected. However, most of the patients were at the University of Gothenburg; 2008. patients, 91%, expected moderate and severe satisfied with the quality of pain management 12. Jeantieu M, Gaillat F, Antonini F, et al. pain after surgery, when questioned prior to received. The findings confirmed the severity Postoperative pain and subsequent ptsd- surgery. When questioned postoperatively, 76% of pain experienced after lung surgery and related symptoms in patients undergoing of the patients experienced such pain levels. demonstrated an apparent need for continued lung resection for suspected cancer. J Interestingly, 81% were satisfied with the pain improvement in postoperative pain manage- Thorac Oncol 2014;9:362-9. management levels. Idvall et al.27 found that ment after lung surgery. Moderate pain still 13. McNamara MC, Harmon D, Saunders J. patients seemed more satisfied with the post- existed among 16% of the patients 6 months Effect of education on knowledge, skills operative pain management than the nurses after surgery. Nevertheless, the sample size in and attitudes around pain. Br J Nurs 2012; assessed them to be. this study was small and only from one hospi- 21:958-64. In this study, 39% of the patients’ had more tal, thus reducing the generalization of the 14. Wilson B. Nurses’ knowledge of pain. 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